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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC REQUEST# <br /> A � <br /> OWNER/OPERATOR <br /> U +Y- C' a n CHECK if BILLING ADDRESS <br /> FACILITY NAME V <br /> SITE ADDRESS__�2_y 5 <br /> Street Number irection Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (M) c5,1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1'l J.� �✓�I /" i �\ �., � � CHECK If BILLING ADDRESS Eq <br /> BUSINESS NAME ili✓ �-. { li l li' PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN-r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that i have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandarWTAa 'FEDER .law ., <br /> APPLICANT'S SIGNATY',� Li(�(��J� DATE: 2 02,0 <br /> PROPERTY/BusmESSOWNERLL OPERATOR/-MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO AUTHORIZATION TO RELEAS��FORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SEWCE REQUESTED: <br /> nJJItY�1ft?_ Loc,�A+►? <br /> COMMENTS: •p Z <br /> CE/VFn <br /> YAY j82 <br /> SAN Vu/NCo02Q <br /> /�0urt <br /> ACCEPTED BY: 1����i EMPLOYEE#: AT <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: V1�/Z 0110 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ,2 Igo,? <br /> Fee Amount: 4_4 D' Amount Paid O Payment Date <br /> In ^ ,\ <br /> Payment Type I� voice# Check# Received By: <br /> EHD 025 SR FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 <br />